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The nurse is assessing a client with hypothermia who is on a ventilator and notes a temperature of 82.5°F (32.2°C). Drag from the list of possible interventions from the left to the right that are the most appropriate for the nurse to implement.

Placing warm blankets on the client

Decreasing temperature in the room

Warm intravenous (IV) fluids

Administer acetaminophen orally every 6 hours

Place a fan on the client

Warmed, humidified oxygen

Place on cardiac monitor

Using a radiant warmer

Monitor core temperature

Answer and Explanation

Correct Answer : A,C,F,G,H,L

A. Warm blankets provide external rewarming.
B. The room should be kept warm, not decreased.
C. Warm IV fluids prevent further heat loss and aid internal rewarming.
D. Acetaminophen is for fever reduction, not for hypothermia management.
E. A fan would worsen heat loss.
F. Warmed, humidified oxygen prevents further cooling and helps raise core body temperature.
G. Cardiac monitoring is essential since hypothermia increases the risk for arrhythmias.
H. A radiant warmer provides effective external rewarming.
I. Monitoring core temperature ensures safe and effective rewarming.

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Correct Answer is A

Explanation

A. Anticipatory grieving occurs when family members begin to experience grief before the actual loss, often in response to a terminal illness.
B. Situational refers to a sudden, unexpected loss or crisis, not the expected progression of a chronic illness.
C. Coping describes strategies used to deal with stress but is not a type of grief.
D. Hope is a positive outlook that may exist alongside grief but is not a form of grieving.

A. Weight gain of 3 pounds in 24 hours B. Decreased muscle strength C. BUN 28 mg/dL (Ref: 10-20 mg/dL) D. Bilateral 2+ pedal pulses

Correct Answer is A

Explanation

A. A weight gain of 3 pounds in 24 hours indicates fluid retention, which can quickly progress to fluid overload, pulmonary edema, and heart failure. This is the priority finding to report.
B. Decreased muscle strength may occur due to electrolyte imbalance or fatigue but is not immediately life-threatening.
C. An elevated BUN is expected in chronic kidney disease and is not as urgent as acute fluid retention.
D. Bilateral 2+ pedal pulses are normal and do not require reporting.

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The nurse is assessing a client with hypothermia who is on a ventilator and notes a temperature of 82.5°F (32.2°C). Drag from the list of possible interventions from the left to the right that are the most appropriate for the nurse to implement.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has end-stage renal disease. The client's child is present and tells the nurse about fears that the disease will soon progress to death. What type of grieving does the nurse identify in the client's child's response?

Correct Answer is A

Explanation

The nurse is assessing a client with chronic kidney disease. Which assessment finding is the priority for the nurse to report?

Correct Answer is A

Explanation

The nurse is caring for a client with cellulitis on the leg. Which statement by the client indicates a need for additional education regarding cellulitis?

The school nurse is educating a group of parents about impetigo. Which statement indicates understanding by the parents?

The school nurse is educating parents on how to care for their child with pediculosis capitis. What will the nurse include when explaining to the parents how to manage pediculosis capitis?

The nurse is educating a client's spouse about anticipatory grief. Which statement made by the spouse indicates understanding?

The nurse is caring for four clients with acute kidney injury. Which client is of highest priority?

The nurse is providing teaching to a young adult who is at risk for early-onset osteoporosis. Which intervention should the nurse suggest?

The nurse is educating a client taking an H2 blocker about peptic ulcer disease. The client is asking the nurse what factors increase the risk of peptic ulcer disease and how to prevent them. What is the most appropriate response by the nurse?